CDC Immunization Related Requirements Test Plan (CNI) v3

This test plan is to be used for the testing of the CDC EHR Immunization Related Requirements developed under Contract-No: 200-2014-60994 . All test cases are required to be executed. The test plan includes both functional and interoperability tests including Vaccine Update Notifications (HL7 V2.5.1 VXU/Z22) and Query and Response (Evaluated History and Forecast Group Z44/Z42).

1. Initial Data Load

The initial Data load will consist of the vendor entering data during live interactive testing for 4 patients with various scenarios. The data entry will include demographic data, Immunization histories and specific conditions for each patient.

1.1. Juana Mariana Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for 6-year old Juana Mariana Gonzales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juana Mariana Gonzales. The data includes immunizations provided by the practice. The vendor also enters: ?? Two vaccines administered at other sites o an influenza vaccine given at a local pharmacy o an inactivated polio vaccine given elsewhere and not reported to the registry - the history includes an adverse reaction (febrile seizure) 8 hours after the vaccine was administered ?? Adverse reaction to inactivated polio vaccine (febrile seizure) and the date and source of information ?? Allergy to egg albumin administered at this site (the registry has different CVX date and lot number information for this vaccine) NOTE: the historical vaccines will be imported during the Registry query (e.g. from another practice)

Description

The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juana Mariana Gonzales. The data includes immunizations provided by the practice.

The vendor also enters:

?? Two vaccines administered at other sites

o an influenza vaccine given at a local pharmacy

o an inactivated polio vaccine given elsewhere and not reported to the registry - the history includes an adverse reaction (febrile seizure) 8 hours after the vaccine was administered

?? Adverse reaction to inactivated polio vaccine (febrile seizure) and the date and source of information

?? Allergy to egg albumin administered at this site (the registry has different CVX date and lot number information for this vaccine)

NOTE: the historical vaccines will be imported during the Registry query (e.g. from another practice)

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions ??in the record created for Juana Mariana Gonzales??using the test data provided.

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

1.1.1. Enter Initial Demographic Data for New Patient Juana Mariana Gonzales, 6-year old

Test Step Type: SUT_MANUAL
Juana Mariana Gonzales is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juana Mariana Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

Test Objectives
*Register New Patients:* The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juana	Y
Patient Name: Middle	Mariana	Y
Patient Name: Last	Gonzales	Y
Patient Date of Birth	11/01/2010	Y
Birth Time	11:05	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	No	Y
Patient Birth Order	NA	C
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Merida	Y
Responsible Person Name: Last	Gonzales	Y
Responsible Person Name: Relationship to Patient	Grandmother	Y
Mother's Name: First	Maria	Y
Mother's Name: Middle	Merida	Y
Mother's Name: Last	Gonzales	Y
Mother's Name: Maiden Last	Acosta	Y
Patient Address: Street	4345 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Shoreline Hospital 325 Shorline Drive, Stamford Connecticut 06901	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1212	Y
Patient Telephone Number Type (e.g., home, cell)	home	Y
Patient E-mail Address	jmg@gmail.com	N
Publicity Code	NA	N
Protection Indicator	NA	N
Protection Indicator Effective Date	NA	N
Immunization Registry Status	NA	N
Preferred Contact Method	Phone	Y

Notes for Testers
No Note

1.1.2. Enter Initial Immunization Data for Juana Mariana Gonzales: Immunizations from practice

Test Step Type: SUT_MANUAL
Patient History from the local practice is entered into the EMR.

Test Story

Description
The EHR vendor loads immunization history data from the local practice for Juana Mariana Gonzales.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

Post Condition
The immunization history the known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Vaccine from Practice HepB

Entering Organization

Shoreline Pediatrics

Administration Notes (Vaccine Event information source)

New immunization record (NIP001 00)

Date/Time of Start of Administration

12/20/2010

Vaccine Administered

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Sandra Molina

Administered-at Location

400 Shoreline Drive, Stamford Connecticut 06901

Lot Number

6352FK1

Substance Expiration Date

12/14/2011

Substance Manufacturer Name

GlaxoSmithKline Biologicals SA (MVX SKB)

Completion Status

Route of Administration

IM (NCIT C28161)

Administration Site

Right Thigh

Vaccine from Practice MMR II

c. Entering Organization

Shoreline Pediatrics

Vaccine Event information source

New immunization record (NIP001 00)

Value/Text for Vaccine Type

MMR II (CVX 03, NDC 0006-4681-00)

Date/Time of Start of Administration

08/22/2011

Vaccine Administered

measles, mumps, rubella virus vaccine

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Sandra Molina

Administered-at Location

400 Shoreline Drive, Stamford Connecticut 06901

Lot Number

0853CC

Substance Expiration Date

12/15/2011

Substance Manufacturer Name

Merck Sharp & Dohme Corp (MVX MSD)

Completion Status

Route of Administration

Subcutaneous (NCIT C28399)

Administration Site

Left Thigh (HL70163 LT)

Notes for Testers
No Note

1.1.3. Enter Initial Immunization Data for Juana Mariana Gonzales from Another Practice

Test Step Type: SUT_MANUAL
Patient History from another practice is entered into the EMR.

Test Story

Description
The EHR vendor loads immunization history data from another practice into the record for Juana Mariana Gonzales.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

Post Condition
The immunization history from another practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from another practice as provided, with all required attributes indicated by [Y]:

Historical Vaccine from Another Practice - Dtap

Entering Organization

Shoreline Pediatrics

Vaccine Event information source (Administration Notes)

Historical information - from parent's written record (NIP001 03)

Value/Text for Vaccine Type

DTaP

Date/Time of Start of Administration

11/20/2014

Vaccine Administered

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) (NDC 49281-0286-01)

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Linda Casera

Administered-at Location

4253 Standish Way, Stamford Connecticut 06903

Lot Number

D643QS8243

Substance Expiration Date

12/1/2014

Substance Manufacturer Name

Sanofi Pasteur Inc (MVX PMC)

Completion Status

Route of Administration

Intramuscular (NCIT C28161)

Administration Site

Left Deltoid (HL70163 LD)

Historical Vaccine from Another Practice - Polio

Entering Organization

Shoreline Pediatrics

Vaccine Event information source

Historical information - from parent's written record (NIP001 03)

Value/Text for Vaccine Type

poliovirus vaccine, inactivated (CVX 10)

Date/Time of Start of Administration

2/21/2012

Vaccine Administered

poliovirus vaccine, inactivated (CVX 10, NDC 49281-0860-55)

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Linda Casera

Administered-at Location

4253 Standish Way, Stamford Connecticut 06903

Lot Number

D335PV9644

Substance Expiration Date

2/22/2013

Substance Manufacturer Name

Sanofi Pasteur Inc (MVX PMC)

Completion Status

Route of Administration

Subcutaneous (NCIT C28399)

Administration Site

Left Deltoid (HL70163 LD)

Reaction

Adverse Reaction of (VXC12^fever of >40.5C (105F) within 48 hours of dose^CDCPHINVS

Notes for Testers
No Note

1.1.4. Enter Initial Immunization Data for Juana Mariana Gonzales Reported by Parent

Test Step Type: SUT_MANUAL
Patient History from a pharmacy as reported by the parent is entered into the EMR.

Test Story

Description
The provider enters immunization data from a pharmacy as reported by the parent for Juana Mariana Gonzales.

Description

The provider enters immunization data from a pharmacy as reported by the parent for Juana Mariana Gonzales.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Gonzales.

Post Condition
The immunization history from the pharmacy as reported by the parent is loaded into the record created for Juana Mariana Gonzales.

Test Objectives
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from the pharmacy as provided by the parent with all required attributes indicated by [Y]:

Historical Vaccine from Pharmacy Reported by Parent
Entered BY	Sandra Molina	Y
Ordering Provider	Gina Ricci	Y
Entering Organization	Shoreline Pediatrics	Y
Vaccine Event information source (Administration Notes)	Historical information - from other provider (NIP001 02)	Y
Value/Text for Vaccine Type	Influenza vaccine	Y
Date/Time of Start of Administration	10/15/2014	Y
Vaccine Administered	influenza, live, intranasal, quadrivalent (CVX 149) FluMist Quadrivalent (NDC 66019-0301-10))	Y
Administered Amount (of Vaccine)	0.2	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Gina Ricci	Y
Administered-at Location	Oceanview Pharmacy, 15 Post Road, Stamford Connecticut 06901	Y
Lot Number	8L4B3423	Y
Substance Expiration Date	06/03/2015	Y
Substance Manufacturer Name	MedImmune, LLC (MVX MED)	Y
Completion Status	CP	Y
Route of Administration	Nasal (NCIT C28384)	Y
Administration Site		Y

Notes for Testers
No Note

1.1.5. Enter Adverse Reaction to the Polio Vaccine

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding adverse events as part of the clinical history.

Test Story

Description
The provider documents in the EMR the clinical history of an adverse reaction to the polio vaccine.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

Post Condition
The clinical history of the adverse reaction to the Polio vaccine is documented in the the record created for Juana Mariana Gonzales.

Test Objectives
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided with all required attributes indicated by [Y]:

Adverse Reaction Substance/Agent	inactivated polio vaccine (e.g. Poliomyelitis vaccine adverse reaction (disorder) 293117006)	Y
Reaction	febrile seizure (e.g. Simple febrile seizure (finding) 432354000) VXC11^convulsions (fits, seizures) within 72 hours of dose^	Y
Date (of the reaction)	8/31/2014	Y

Notes for Testers
No Note

1.1.6. Enter allergy to egg albumin

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding allergies as part of the clinical history.

Test Story

Description
The provider documents in the EMR the clinical history of an allergy to egg albumin.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

Post Condition
The clinical history of the allergy to egg albumin is documented in the record created for Juana Mariana Gonzales

Test Objectives
Supporting data for: Modify Antigen Recommendations Based on Allergy History: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s active allergies.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical allergy data provided with all required attributes indicated by [Y]:

Allergy Sugstance/Agent	Egg Albumin Allergy (e.g. 213020009 Egg protein allergy (disorder), Allergy to eggs (disorder) 91930004)	Y
Date (allergy status known - e.g. thru testing or date of the allergy)	8/31/2014	Y

Notes for Testers
No Note

1.2. Juan Marcel Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for 3 1/2-year old Juan Marcel Gonzales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juan Macel Gonzales. The data includes a clinical history of Asthma.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juan Marcel Gonzales using the test data provided.

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

1.2.1. Enter Initial Demographic Data for New Patient Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
Juan Marcel Gonzales is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juan Marcel Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juan	Y
Patient Name: Middle	Marcel	Y
Patient Name: Last	Gonzales	Y
Patient Date of Birth	03/04/2014	Y
Birth Time	11am	N
Patient Gender (Administrative Sex)	M	Y
Patient Multiple Birth Indicator	No	Y
Patient Birth Order	NA	C
Responsible Person Name: First	Manuel	Y
Responsible Person Name: Middle	Marcel	Y
Responsible Person Name: Last	Gonzales	Y
Responsible Person Name: Relationship to Patient	Father	Y
Mother's Name: First	Anita	Y
Mother's Name: Middle	Francesca	Y
Mother's Name: Last	Gonzales	Y
Mother's Name: Maiden Last	Morales	Y
Patient Address: Street	4623 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Shoreline Hospital 325 Shorline Drive, Stamford Connecticut 06901	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1213	Y
Patient Telephone Number Type (e.g., home, cell)	Home	Y
Patient E-mail Address	None	N
Publicity Code		N
Protection Indicator		N
Protection Indicator Effective Date		N
Immunization Registry Status		N
Preferred Contact Method	Phone	Y

Notes for Testers
No Note

1.2.2. Enter Clinical History for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding a problem of Asthma as part of the clinical history.

Test Story

Description
The clinical history of Moderate Persistent Asthma is documented in the record created for Juan Marcel Gonzales.

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

Post Condition
The clinical history of the Moderate Persistent Asthma is documented in the record created for Juan Marcel Gonzales.

Test Objectives
Supporting data for testing contraindications.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical history data provided with all required attributes indicated by [Y]:

Adverse History of Asthma
Problems	Moderate Persistent Asthma (e.g. Moderate persistent asthma - SNOMED-CT 427295004)	Y	Coded value expected using SNOMED-CT or ICD

Notes for Testers
No Note

1.3. Mariela Gonzales Morales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Mariela Gonzales Morales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for twin Mariela Gonzales Morales.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Mariela Gonzales Morales using the test data provided.

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

1.3.1. Enter Initial Demographic Data for Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
Mariela Gonzales Morales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Mariela Gonzales Morales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic in the record created for Mariela Gonzales Morales.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Mariela	Y
Patient Name: Middle	Gonzales	Y
Patient Name: Last	Morales	Y
Patient Date of Birth	10/01/2015	Y
Birth Time	11am	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	Yes	Y
Patient Birth Order	1	C
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Elena	Y
Responsible Person Name: Last	Morales	Y
Responsible Person Name: Relationship to Patient	Mother	Y
Mother's Name: First	Joanna	Y
Mother's Name: Middle	Elena	Y
Mother's Name: Last	Morales	Y
Mother's Name: Maiden Last	Gonzales	Y
Patient Address: Street	3321 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1214	Y
Patient Telephone Number Type (e.g., home, cell)	home	Y
Patient E-mail Address	none	N
Publicity Code	NA	N
Protection Indicator	NA	N
Protection Indicator Effective Date	NA	N
Immunization Registry Status	NA	N
Preferred Contact Method	none

Notes for Testers
No Note

1.4. Juana Maria Gonzales Morales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Juana Maria Gonzales Morales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for twin Juana Maria Gonzales Morales.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juana Maria Gonzales Morales using the test data provided.

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

1.4.1. Enter Initial Demographic Data for Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
Juana Maria Gonzales Morales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juana Maria Gonzales Morales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre Condition
No PreCondition

Post Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Maria Gonzales Morales.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juana	Y
Patient Name: Middle	Maria Gonzales	Y
Patient Name: Last	Morales	Y
Patient Date of Birth	10/01/2015	Y
Birth Time	11:15am	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	Yes	Y
Patient Birth Order	2	Y
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Elena	Y
Responsible Person Name: Last	Morales	Y
Responsible Person Name: Relationship to Patient	Mother	Y
Mother's Name: First	Joanna	Y
Mother's Name: Middle	Elena	Y
Mother's Name: Last	Morales	Y
Mother's Name: Maiden Last	Gonzales	Y
Patient Address: Street	3321 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1214	Y
Patient Telephone Number Type (e.g., home, cell)	home	Y
Patient E-mail Address	none	N
Publicity Code		N
Protection Indicator		N
Protection Indicator Effective Date		N
Immunization Registry Status		N
Preferred Contact Method	none

]

Notes for Testers
No Note

2. Juana Mariana Gonzales Visit

No Description

2.1. Query the Registry for Juana Mariana Gonzales

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariana Gonzales. The Z42 response is used to display, reconcile, and update the immunization information in the EMR.

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariana Gonzales.
Querying the registry will consist of the vendor creating Z44 messages for Juana Mariana Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Using the Z42 Response to Immunization Registry Query, the EMR displays the Evaluated History and Forecast to the user for reconciliation and update. The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information.

Comments
No Comments

Pre Condition
Juana Mariana Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariana Gonzales Initial Data Load'

Post Condition
A Z44 Query is generated and submitted to the Immunization Registry/Test tool.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria
The vendor can produce a valid Z44 query in accordance with the test data correctly and without ommission. The data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes for Testers
No Note

2.1.1. Select Patient Juana Mariana Gonzales

Test Step Type: SUT_MANUAL
Select patient Juana Mariana Gonzales, distinguishing the patient from other patients with similar demographics (similar names).

Test Story

Description
Juana Mariana Gonzales is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre Condition
Juana Mariana Gonzales Initial Data Load completed.

Post Condition
Juana Mariana Gonzales is the active working patient in the EMR.

Test Objectives

Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Tester shall verify that the product can distinguish Juana Mariana Gonzales from similar sounding names using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juana
Patient Name: Middle - Mariana
Patient Date of Birth - 11/01/2010
Birth Time - 11:05
Patient Gender (Administrative Sex) - F
Patient Multiple Birth Indicator - No
Patient Birth Order - NA
Responsible Person Name: First - Joanna
Responsible Person Name: Middle - Merida
Responsible Person Name: Last - Gonzales
Responsible Person Name: Relationship to Patient - Grandmother (or Grandparent)
Mother's Name: First - Maria
Mother's Name: Middle -Merida
Mother's Name: Last - Gonzales
Mother's Name: Maiden Last - Acosta
Patient Address: Street - 4345 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Shoreline Hospital 325 Shorline Drive, Stamford Connecticut 06901
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1212
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address - jmg@gmail.com
Publicity Code
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Phone

Notes for Testers
No Note

2.1.2. Query Registry for vaccination history and forecast for Juana Mariana Gonzales

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre Condition
Juana Mariana Gonzales Initial Data Load is completed.

Post Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Mariana Gonzales

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20150615001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551212	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N	Value-Test Case Fixed
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20150615001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551212	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N	Value-Test Case Fixed
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Acosta
ID Number	123456
Date/Time of Birth	11/01/2010 11:05
Sex	Female
Patient Address	4345 Standish Way Stamford CT 06903
Patient Phone	(203)555-1212
Birth Indicator	No
Birth Order

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Acosta
ID Number	123456
Date/Time of Birth	11/01/2010 11:05
Sex	Female
Patient Address	4345 Standish Way Stamford CT 06903
Patient Phone	(203)555-1212
Birth Indicator	No
Birth Order

2.1.3. View and Compare response to request for vaccination history for Juana Mariana Gonzales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and compare to those in the EMR.

Test Story

Description

The Immunization Registry returns an Evaluated History and Forecast (Z42) to the EMR in response to the query for patient (Juana Mariana Gonzales). The provider reviews the immunization history from the registry and compares to the immunization history in the EMR. The provider reconciles the information from these sources, importing information known only to the registry, retaining information that is more accurately reflected in the local EMR:

The physician accesses the record for Juana Mariana Gonzales and:

• Reconciles the EHR vaccine history with the history retrieved from the registry:

o Accepts new vaccines from the registry data

o If the EHR does not already flag the first MMRV as invalid, the provider updates the first MMRV to indicate it is “invalid” as it was given too early (as notified by the registry)

o Retains the local history for influenza and polio vaccines that are not included in the registry report.

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales)

Test Objectives

Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient’s local immunization history and include the time of the update and the source of the new information.

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Evaluation Criteria
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	9
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20110221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20110221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20111123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20111123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20120523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20120523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160131
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	9
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20110221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20110221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20111123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20111123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20120523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20120523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160131
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Mariana Gonzales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juana Mariana Gonzales
Date of Birth	11/01/2010
Sex	Female
Address 1
Street	4345 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Maria Merida Acosta
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	11/01/2010
Date/Time Administration-End	11/01/2010
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, unspecified formulation
Refusal Reason
Date/Time Administration-Start	12/20/2010
Date/Time Administration-End	12/20/2010
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	05/20/2011
Date/Time Administration-End	05/20/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	02/21/2012
Date/Time Administration-End	02/21/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	11/21/2011
Date/Time Administration-End	11/21/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/11/2012
Date/Time Administration-End	01/11/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	09/25/2011
Date/Time Administration-End	09/25/2011
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/29/2011
Date/Time Administration-End	10/29/2011
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/02/2012
Date/Time Administration-End	10/02/2012
Administered Amount	.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	11/04/2013
Date/Time Administration-End	11/04/2013
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	11/23/2011
Date/Time Administration-End	11/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	05/23/2012
Date/Time Administration-End	05/23/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Shoreline Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	08/22/2011
Date/Time Administration-End	08/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	Sandra Molina
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	400 Shoreline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	NO
Validity Reason	Early
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	11/22/2014
Date/Time Administration-End	11/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Varicella virus vaccine
Vaccine Administered	varicella virus vaccine
Refusal Reason
Date/Time Administration-Start	12/15/2012
Date/Time Administration-End	12/15/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Right Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	04/30/2011
Earliest Date to Give	04/30/2011
Latest Date to Give	04/29/2012
Date When Vaccine Overdue	04/30/2012
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2015
Earliest Date to Give	09/01/2015
Latest Date to Give	01/31/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason

2.1.4. Mark first MMR Dose as Invalid

Test Step Type: SUT_MANUAL
Identify the first MMR dose which is given too early, as invalid. If the EHR does not already flag the first MMR as invalid, the provider updates the first MMR to indicate it is ?invalid? as it was given too early (as notified by the registry).

Enter an MMR dose at 14 days prior to the current date. As the first MMR was invalid, this should be listed as the first dose.

Test Story

Description
If the EHR does not already flag the first MMRV as invalid, the provider updates the first MMRV to indicate it is "invalid" as it was given too early (as notified by the registry)

Comments
If the EMR already recognizes the dose as invalid, then this step may be skipped.

Pre Condition
Initial Data Load

Post Condition
MMRV status for the first MMRV dose is set to invalid.

Test Objectives
dose validity is an important aspect of: Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Vendor Records 2nd historical MMR dose two weeks prior to the current test date.

Evaluation Criteria: The vendor is able to record that the first MMR vaccination dose is invalid with a reason that it was given too early, and therefore this new dose should be indicated as dose '1'.

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Vaccine from Practice HepB
Entered BY	Sandra Molina	Y
Ordering Provider	Frank Smith	Y
Entering Organization	Shoreline Pediatrics	Y
Administration Notes (Vaccine Event information source)	New immunization record (NIP001 00)	Y
Date/Time of Start of Administration	14 days prior to the Current Date	Y
Vaccine Administered	MMR (CVX 03, NDC 0006-4681-00 - MMR II)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Sandra Molina	Y
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901	Y
Lot Number	0934GG	Y
Substance Expiration Date	10/31/2016	Y
Substance Manufacturer.	Merck Sharp & Dohme Corp (MVX MSD)	Y
Completion Status	CP	Y
Route of Administration	Subcutaneous (NCIT C28399)	Y
Administration Site	Left Deltoid	Y

Notes for Testers
No Note

2.1.5. View the vaccination forecast for Juana Mariana Gonzales

Test Step Type: TA_RESPONDER
Vendor can successfully display the current Immunization Forecast (vaccination names and recommended vaccination dates) as returned by the Registry (Z42).

Test Story

Description

The physician accesses the record for Juana Mariana Gonzales and:

• Displays the registry forecast which includes the need for a second, valid MMRV vaccine and also the need for influenza and polio vaccines (since the registry has no information about them)

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales)

Test Objectives
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast.

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. Verify that All forecast vaccines and dates returned by the registry are displayed to the user.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	9
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20110221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20110221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20111123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20111123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20120523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20120523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160131
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201011011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20100522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	9
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20110221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20110221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20111123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20111123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20120523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	20120523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20110430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20120430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160131
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161030
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Mariana Gonzales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juana Mariana Gonzales
Date of Birth	11/01/2010
Sex	Female
Address 1
Street	4345 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Maria Merida Acosta
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	11/01/2010
Date/Time Administration-End	11/01/2010
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, unspecified formulation
Refusal Reason
Date/Time Administration-Start	12/20/2010
Date/Time Administration-End	12/20/2010
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	05/20/2011
Date/Time Administration-End	05/20/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	02/21/2012
Date/Time Administration-End	02/21/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	11/21/2011
Date/Time Administration-End	11/21/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	05/22/2011
Date/Time Administration-End	05/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/11/2012
Date/Time Administration-End	01/11/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	01/22/2011
Date/Time Administration-End	01/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	03/23/2011
Date/Time Administration-End	03/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	09/25/2011
Date/Time Administration-End	09/25/2011
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/29/2011
Date/Time Administration-End	10/29/2011
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/02/2012
Date/Time Administration-End	10/02/2012
Administered Amount	.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	11/04/2013
Date/Time Administration-End	11/04/2013
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	11/23/2011
Date/Time Administration-End	11/23/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	05/23/2012
Date/Time Administration-End	05/23/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Shoreline Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	08/22/2011
Date/Time Administration-End	08/22/2011
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	Sandra Molina
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	400 Shoreline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	NO
Validity Reason	Early
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	11/22/2014
Date/Time Administration-End	11/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Varicella virus vaccine
Vaccine Administered	varicella virus vaccine
Refusal Reason
Date/Time Administration-Start	12/15/2012
Date/Time Administration-End	12/15/2012
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Right Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	04/30/2011
Earliest Date to Give	04/30/2011
Latest Date to Give	04/29/2012
Date When Vaccine Overdue	04/30/2012
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2015
Earliest Date to Give	09/01/2015
Latest Date to Give	01/31/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/31/2014
Earliest Date to Give	10/31/2014
Latest Date to Give	10/30/2016
Date When Vaccine Overdue	10/31/2016
Status in Immunization Series
Forecast Reason

2.1.6. Reconcile and import vaccinations from Evaluated History and Forecast for Juana Mariana Gonzales

Test Step Type: SUT_MANUAL
The Provider uses the EMR to compare the immunization history results (Z42) returned by the Immunization Registry in response to the Z44 Query with the immunization history in the local system, and reconcile (import/update) records.

Test Story

Description
Juana Maria Gonzales Morales immunization registry provided Evaluated History and Forecast is reconciled with the Immunization history information in the EMR.

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales)

Test Objectives

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Evaluation Criteria

1. The user imports returned vaccinations as follows:

a. Vaccinations NOT imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 12/20/2010

measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 8/22/2011

VERIFY that the dose validity is marked as invalid

b. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/01/2010

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 05/20/2011

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2011

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2011,

Including adverse reaction 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2011

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2012

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/21/2011

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2011

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2011

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/21/2011

poliovirus vaccine, inactivated (CVX 10) administered 1/22/2011

poliovirus vaccine, inactivated (CVX 10) administered 3/23/2011

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2011

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2011

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2011

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/11/2012

rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2011

rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2011

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2011

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/29/2011

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2012

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2013

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2011

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2012

measles, mumps, rubella virus vaccine (CVX 94) administered 11/22/2014

Varicella virus vaccine (CVX 94) administered 12/15/2012

Notes for Testers
No Note

2.1.7. View the updated vaccination forecast for Juana Mariana Gonzales

Test Step Type: SUT_MANUAL
Using the reconciled vaccine history information, the EMR displays the current Immunization Forecast to the user for Juana Mariana Gonzales.

Test Story

Description
Once the vaccine history is reconciled in the EMR, the vaccine forecast is updated.

Comments
No Comments

Pre Condition
EMR Vaccine History is Reconciled with Immunization History from the IIS (previous step 'Reconcile and import vaccinations from Evaluated History and Forecast returned by the Registry for Juana Mariana Gonzales').

Post Condition
An updated vaccine forecast based upon the reconciled vaccine history is available to the user.

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:

1. Verify that the EMR does not include in reconciled vaccine forecast:

IPV due on 4/30/2011

2. Verify that the EMR includes in reconciled vaccine forecast:

IPV due on 10/31/2014

MMR due on 10/31/2014

Varicella due on 10/31/2014

influenza, unspecified formulation due on 09/01/2015

Notes for Testers
No Note

2.2. Juana Mariana Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

2.2.1. Order IPV and view prior reaction

Test Step Type: SUT_MANUAL
The provider selects to order IPV and views information about the prior febrile seizure post-IPV vaccine.

Test Story

Description

The physician accesses the record for Juana Mariana Gonzales and:

• Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

Post Condition
IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures).

Test Objectives
Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	IPV (CVX 10)
Date/Time Vaccine Refusal was recorded	Current Date
Alert	Alerts user to information about the prior febrile seizure post-IPV vaccine

Notes for Testers
No Note

2.2.2. IPV Parental Refusal

Test Step Type: SUT_MANUAL
Documents mother?s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent.

Test Story

Description
The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother’s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent.

Comments
No Comments

Pre Condition
Prior Immunization History loaded and reconciled from the Immunization Registry. Order is attempted for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures.

Post Condition
Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is permanent.

Test Objectives
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

EMR documents the non-administration of the IPV due to the parental refulsal:

Substance/Treatment Refusal Reason	Parental decision (NIP002 00)
Completion Status	RE
Date/Time Vaccine Deferral was recorded	Current Date
Deferral Reason	Parental decision (NIP002 00)
Deferral Status	Permanent

Notes for Testers
No Note

2.2.3. Order Influenza vaccine and view allergy alert

Test Step Type: SUT_MANUAL
The provider orders inactivated influenza vaccine and is notified that the patient as allergy to egg albumin.

Test Story

Description
The provider orders inactivated influenza vaccine and is notified that the patient as allergy to egg albumin

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

Post Condition
Intranasal form of the Influenza vaccine is ordered for the patient.

Test Objectives
Modify Antigen Recommendations Based on Allergy History: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s active allergies.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Order Value/Text for Vaccine Type	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX161)
Date/Time Vaccine was recorded	Current Date
Alert	Alerts user to information that patient has Egg Allergy

Provider changes the order to modifies the Vaccine type:

Vaccine Type:

Influenza virus vaccine, live, attenuated, for intranasal use (CVX 111)

Notes for Testers
No Note

2.2.4. Attempt to order Varicella Dose

Test Step Type: SUT_MANUAL
No Description

Test Story

Description
The provider attempts to give a Varicella dose, and is warned that it is too soon to give a live vaccine dose.

Comments
No Comments

Pre Condition
MMR dose entered at 14 days prior to the current date.

Post Condition
The provider has been issued a warning that it is too soon to give another live virus dose.

Test Objectives

Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Evaluation Criteria
There should be a warning that the attempt to give a new Varicella Dose is too early - should get warning that 28 days must pass between 2 live virus vaccines if not administered at the same time due to the prior MMR vaccination 14 days earlier.

Notes for Testers
No Note

2.2.5. Records Influenza Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration in the EMR and is prevented from incorrectly documenting vaccine route.

Test Story

Description
The nurse documents administration route for the nasal live, attenuated influenza vaccine • Is prevented from documenting “IM” for live, attenuated influenza vaccine

Comments
This step covers data quality checking as an informative aspect of vaccine administration

Pre Condition
Order is placed for nasal live, attenuated influenza vaccine.

Post Condition
The nasal live, attenuated influenza vaccination route has failed to be recorded as intramuscular in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Sample of data quality checking for vaccine route.

Evaluation Criteria
The EMR prevents the user for entering 'Intramuscular' as a route for the the nasal live, attenuated influenza vaccine.

Notes for Testers
No Note

2.2.6. Record Influenza Vaccine administration

Test Step Type: SUT_MANUAL
The provider documents in the EMR all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the the nasal live, attenuated influenza vaccine
• Documents all required information for each vaccine

Comments
No Comments

Pre Condition
Order is placed for nasal live, attenuated influenza vaccine.

Post Condition
The nasal live, attenuated influenza vaccinations is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source (Administration Notes)	New immunization record (NIP001 00)
Value/Text for Vaccine Type	influenza virus vaccine, live, attenuated, for intranasal use (CVX 111), FluMist Quadrivalent (NDC 66019-0301-10)
Date/Time of Start of Administration	Current Date
Vaccine Administered	influenza virus vaccine, live, attenuated, for intranasal use (CVX 111), FluMist Quadrivalent (NDC 66019-0301-10)
Administered Amount (of Vaccine)	0.2
Administered Units (of Measure)	mL
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	8L4B3521
Substance Expiration Date	8/15/2015
Substance Manufacturer Name	MedImmune,LLC (MVX MED)
Completion Status	CP
Route of Administration	Nasal (NCIT C38284), Nasal (HL70162 NS)
Administration Site
VFC Eligibility	No

Notes for Testers
No Note

2.2.7. Records MMRV Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration route in the EMR and is prevented from incorrectly documenting vaccine route

Test Story

Description
The nurse documents administration route for the MMRV vaccine • Is prevented from documenting “oral” for MMRV vaccine

Comments
This step covers data quality checking as an informative aspect of vaccine administration

Pre Condition
Order is placed for MMRV vaccine.

Post Condition
The MMRV vaccination route has failed to be recorded as 'oral' in the EMR.

Test Objectives

Evaluation Criteria
The EMR prevents the user for entering 'Oral' as a route for the the MMRV vaccine.

Notes for Testers
No Note

2.2.8. Record MMRV Vaccine administration

Test Step Type: SUT_MANUAL
The provider documents in the EMR all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the the MMRV vaccine
• Documents all required information for each vaccine

Comments
No Comments

Pre Condition
Order is placed for MMRV vaccine.

Post Condition
The MMRV vaccination is recorded in the EMR.

Test Objectives

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Order Value/Text for Vaccine Type	measles, mumps, rubella, and varicella virus vaccine (CVX 94 ), ProQuad (NDC 00006-4999-00)
Date/Time Vaccine was recorded	Current Date
Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	measles, mumps, rubella, and varicella virus vaccine (CVX 94 ), ProQuad (NDC 00006-4999-00)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administration Notes
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	7W87V3687
Substance Expiration Date	7/15/2015
Substance Manufacturer Name	Merck Sharp & Dohme Corp (MVX MSD)
Completion Status	CP
Route of Administration	Subcutaneous (NCIT C38299, HL70162: SC)
Administration Site	Left Deltoid (HL70162 LD)
VFC Eligibility	No

Notes for Testers
No Note

2.3. Juana Mariana Gonzales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juana Mariana Gonzales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

Pre Condition
The vaccines for the visit have been administered.

Post Condition
No PostCondition

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

2.3.1. Transmit the immunization report to the Immunization Registry

Test Step Type: SUT_INITIATOR
The EMR send the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

Pre Condition
The vaccines for the visit have been administered.

Post Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	HL70005
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	4345 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	GRP
NK1-3.2	Text	Grandparent
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06901
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551212

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	Historical Immunization
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK1
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141130
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D643QS8243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00
RXA-18.2	Text	Parental decision
RXA-18.3	Name of Coding System	NIP002
RXA-20	Completion Status	RE
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110121
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV932
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	03
RXA-9.2	Text	Historical information - from parents written record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3423
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune, LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.2
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3521
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160815
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune,LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151015
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	3452DD
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	HL70005
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	4345 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	GRP
NK1-3.2	Text	Grandparent
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06901
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551212

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	Historical Immunization
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK1
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141130
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D643QS8243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00
RXA-18.2	Text	Parental decision
RXA-18.3	Name of Coding System	NIP002
RXA-20	Completion Status	RE
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110121
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV932
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	03
RXA-9.2	Text	Historical information - from parents written record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3423
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune, LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.2
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3521
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160815
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune,LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151015
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	3452DD
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2010 11:05
Administrative Sex	Female
Patient Address 1	4345 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Gonzales
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2010
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2010
Administered Amount	999
Administered Units
Administration Notes	Historical Immunization
Administering Provider	Sandra Molina
Substance Lot Number	6352FK1
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/30/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2012
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	02/22/2013
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2012
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV932
Substance Expiration Date	05/10/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2013
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2013
Administered Amount	999
Administered Units
Administration Notes	Historical information - from parents written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	04/30/2014
Substance Manufacturer Name	MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/31/2015
Administered Amount	0.2
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	08/15/2016
Substance Manufacturer Name	MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2011
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2015
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	12/15/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	3452DD
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2010 11:05
Administrative Sex	Female
Patient Address 1	4345 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Gonzales
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2010
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2010
Administered Amount	999
Administered Units
Administration Notes	Historical Immunization
Administering Provider	Sandra Molina
Substance Lot Number	6352FK1
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/30/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2012
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	02/22/2013
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2012
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV932
Substance Expiration Date	05/10/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2013
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2013
Administered Amount	999
Administered Units
Administration Notes	Historical information - from parents written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	04/30/2014
Substance Manufacturer Name	MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/31/2015
Administered Amount	0.2
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	08/15/2016
Substance Manufacturer Name	MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2011
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2015
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	12/15/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	3452DD
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

2.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre Condition
A VXU message is generated by the EHR.

Post Condition
The ACK Z23 is received by the EHR.

Test Objectives
No Test Objectives

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes for Testers
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

2.3.3. Record an adverse reaction

Test Step Type: SUT_MANUAL
The Provider records in the EMR an adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose.

Test Story

Description
Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours.

Comments
No Comments

Pre Condition
The vaccinations for the visit have been administered.

Post Condition
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR.

Test Objectives
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Evaluation Criteria
Verify that vendor can record the adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission

Notes for Testers
No Note

2.3.4. Transmit the updated vaccination report with adverse reaction to the registry

Test Step Type: SUT_INITIATOR
The EMR generates a Z22 Send Unsolicited Immunization Update Using a VXU correctly and without omission according to supplied test data.

Test Story

Description
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message.

Comments
No Comments

Pre Condition
An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR.

Post Condition
The adverse reaction has been transmitted to the IIS.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	HL70005
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	4345 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	GRP
NK1-3.2	Text	Grandparent
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06901
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551212

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	Historical Immunization
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK1
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141130
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D643QS8243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00
RXA-18.2	Text	Parental decision
RXA-18.3	Name of Coding System	NIP002
RXA-20	Completion Status	RE
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110121
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV932
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	03
RXA-9.2	Text	Historical information - from parents written record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3423
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune, LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.2
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3521
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160815
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune,LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151015
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	3452DD
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC9
OBX-5.2	Text	persistent, inconsolable crying lasting > 3 hours within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201011011105
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	HL70005
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	4345 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	GRP
NK1-3.2	Text	Grandparent
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06901
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551212

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20101220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	Historical Immunization
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK1
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141130
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D643QS8243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120221
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02
RXA-9.2	Text	Historical information - from other provider
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00
RXA-18.2	Text	Parental decision
RXA-18.3	Name of Coding System	NIP002
RXA-20	Completion Status	RE
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110121
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV932
RXA-16	Substance Expiration Date
RXA-16.1	Time	20110510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	03
RXA-9.2	Text	Historical information - from parents written record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3423
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune, LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	149
RXA-5.2	Text	influenza, live, intranasal, quadrivalent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.2
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	8L4B3521
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160815
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MED
RXA-17.2	Text	MedImmune,LLC
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20111123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20120523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20120911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20110822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20111215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151015
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01
RXA-9.2	Text	historical
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20121215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	New immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	3452DD
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38284
RXR-1.2	Text	Nasal
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100522
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC9
OBX-5.2	Text	persistent, inconsolable crying lasting > 3 hours within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2010 11:05
Administrative Sex	Female
Patient Address 1	4345 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Gonzales
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2010
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2010
Administered Amount	999
Administered Units
Administration Notes	Historical Immunization
Administering Provider	Sandra Molina
Substance Lot Number	6352FK1
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/30/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2012
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	02/22/2013
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2012
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV932
Substance Expiration Date	05/10/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2013
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2013
Administered Amount	999
Administered Units
Administration Notes	Historical information - from parents written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	04/30/2014
Substance Manufacturer Name	MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/31/2015
Administered Amount	0.2
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	08/15/2016
Substance Manufacturer Name	MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2011
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2015
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	12/15/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	3452DD
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig
Reaction	persistent, inconsolable crying lasting > 3 hours within 48 hours of dose

Patient Information

Element	Data
Patient Name	Juana Mariana Gonzales
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2010 11:05
Administrative Sex	Female
Patient Address 1	4345 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Gonzales
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2010
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2010
Administered Amount	999
Administered Units
Administration Notes	Historical Immunization
Administering Provider	Sandra Molina
Substance Lot Number	6352FK1
Substance Expiration Date	12/14/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/30/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2012
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2011
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2012
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	02/22/2013
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/21/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2011
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2012
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV932
Substance Expiration Date	05/10/2011
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2013
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2013
Administered Amount	999
Administered Units
Administration Notes	Historical information - from parents written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	04/30/2014
Substance Manufacturer Name	MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	influenza, live, intranasal, quadrivalent
Date/Time Start of Administration	10/31/2015
Administered Amount	0.2
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	08/15/2016
Substance Manufacturer Name	MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Nasal
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2011
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2012
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2012
Substance Manufacturer Name	Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2011
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2011
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2014
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2015
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	12/15/2012
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2013
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	3452DD
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig
Reaction	persistent, inconsolable crying lasting > 3 hours within 48 hours of dose

2.3.5. Receive ACK Z23 from Immunization Registry for Updated Transmission

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre Condition
A VXU message is generated by the EHR.

Post Condition
The ACK Z23 is received by the EHR.

Test Objectives
No Test Objectives

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes for Testers
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

2.4. Juana Mariana Gonzales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

2.4.1. Produce an immunization report for Juana Mariana Gonzales including all history

Test Step Type: SUT_MANUAL
The EMR is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
*Produce Standard Patient Immunization History Report:* The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria

The following patient demographics are displayed:

Patient Identifier Number: Vendor Assigned

Patient Identifier Type Code: Vendor Assigned

Patient Name: Juana Mariana Gonzales

Date/Time of Birth: 11/01/2010 11:05am

Sex: Female

Patient Address: 4345 Standish Way, Stamford, CT, 06903

Multiple Birth: N

Birth Order: NA

The following Vaccination History is displayed:

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 11/01/2010

Additional Observations: None

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Jane Carter

Entered By: Lisa Sirtis

Entering Organization: Shoreline Hospital

Administered Amt: .05 mL

Administering Provider: Jane Carter

Administered at Location: 325 Shorline Drive,

Stamford Connecticut 06901

Lot#: 6332FK33

Exp Date: 12/14/2011

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 12/20/2010

Additional Observations: None

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Frank Smith

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shorline Drive,

Stamford Connecticut 06901

Lot#: 6352FK1

Exp Date: 12/14/2011

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 05/20/2011

Additional Observations: None

Dose #: 3

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6352FK24

Exp Date: 8/31/2012

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 1/22/2011

Additional Observations: None

Dose #: 1

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS2341

Exp Date: 11/30/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)

Date Administered: 3/23/2011

Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose

Dose #: 2

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS2433

Exp Date: 9/4/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 5/22/2011

Additional Observations:

Dose #: 3

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS3255

Exp Date: 12/1/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 2/21/2012

Additional Observations:

Dose #: 4

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS249

Exp Date: 3/1/2012

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 11/30/2014

Additional Observations:

Dose #: 5

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .05 mL

Administering Provider: Linda Casera

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D643QS8243

Exp Date: 12/01/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 1/21/2011

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M54K9245

Exp Date: 3/24/2011

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 3/23/2011

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M55K3342

Exp Date: 10/30/2011

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 5/22/2011

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M75K4566

Exp Date: 5/23/2011

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 11/21/2011

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M53K5534

Exp Date: 2/22/2012

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 1/22/2011

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D333PV2431

Exp Date: 10/4/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 3/23/2011

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D333PV4344

Exp Date: 3/23/2012

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 2/21/2012

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D335PV9644

Exp Date: 2/22/2013

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 1/22/2010

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P243V3281

Exp Date: 1/30/2010

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 3/23/2010

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P343V8321

Exp Date: 3/30/2010

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 5/22/2010

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P853V2164

Exp Date: 8/30/2010

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 2/21/2011

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P853V58532

Exp Date: 4/18/2011

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 1/22/2010

Additional Observations:

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RV533

Exp Date: 2/15/2010

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 3/23/2010

Additional Observations:

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RV932

Exp Date: 5/10/2011

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 9/25/2010

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D8043IN8734

Exp Date: 3/12/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 10/27/2010

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D8043IN8734

Exp Date: 3/12/2011

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 10/2/2011

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D9334IN9333

Exp Date: 5/22/2012

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 11/4/2012

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D9553IN2243

Exp Date: 4/30/2012

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: influenza, unspecified formulation

Administered: influenza, live, intranasal, quadrivalent (CVX 149)

FluMist Quadrivalent (NDC 66019-0301-10)"

Date Administered: Current Date

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Sandra Molina

Entered By: Frank Smith

Entering Organization: Oceanview Pediatrics

Administered Amt: .2 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: 8L4B3521

Exp Date: 7/15/2015

Manufacturer: MedImmune,LLC (MVX MED)

Route: Nasal (NCIT C38284), Nasal (HL70162 NS)

Site:

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: 11/23/2011

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RT33

Exp Date: 1/4/2012

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Deltoid (HL7 RD)

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: 5/23/2012

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RT48

Exp Date: 9/11/2012

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (NDC 0006-4681-00)"

Date Administered: 08/22/2011

Additional Observations:

Dose #:

Doses in Series: 2

Valid Dose: N

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 0853CC

Exp Date: 12/15/2011

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Thigh (HL7 LT)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (0006-4681-00)"

Date Administered: 11/22/2014

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 0854FF

Exp Date: 4/13/2015

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (NDC 0006-4681-00)"

Date Administered: 14 days PRIOR to day of TEST

Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS VXC12)

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Sandra Molina

Entered By: Frank Smith

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: 0934GG

Exp Date: 10/15/2016

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: Varicella

Administered: Varicella vaccine (CVX 21)

VarivaxI (NDC 0006-4827-00)"

Date Administered: 12/15/2012

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Martinez

Entered By: Carlos Herrera

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 2341BB

Exp Date: 12/1/2013

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: Varicella

Administered: Varicella vaccine (CVX 21)

VarivaxI (NDC 0006-4827-00)"

Date Administered: Date of Test

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Martinez

Entered By: Carlos Herrera

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 3452DD

Exp Date: 12/1/2016

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Right Deltoid (HL7 RD)The Following Vaccine Forecast is displayed:

Vaccine Group: IPV

Due Date: 11/22/2013

Earliest Date to Give: 11/22/2013

Latest Date to Give: 11/22/2015

Overdue Date: 11/23/2015

Immunization Schedule: ACIP

Vaccine Group: influenza, unspecified formulation

Due Date: 10/21/2016

Earliest Date to Give: 9/1/2016

Latest Date to Give: 2/29/2017

Overdue Date: 3/1/3027

Immunization Schedule: ACIP

Notes for Testers
No Note

3. Juan Marcel Gonzales Visit

No Description

3.1. Query the Registry for Juan Marcel Gonzales

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juan Marcel Gonzales.

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juan Marcel Gonzales. Querying the registry will consist of the vendor creating Z44 messages for Juan Marcel Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

3.1.1. Select Patient Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
Select patient Juan Marcel Gonzales, distinguishing the patient from other patients with similar demographics (similar names).

Test Story

Description
Juan Marcel Gonzales is selected as the patient and his record is opened in the EMR.

Comments
No Comments

Pre Condition
Juan Marcel Gonzales Initial Data Load completed.

Post Condition
Juan Marcel Gonzales is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Juan Marcel Gonzales from similar sounding names using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juan
Patient Name: Middle - Marcel
Patient Name: Last - Gonzales
Patient Date of Birth - 03/04/2014
Birth Time - 11:00
Patient Gender (Administrative Sex) - M
Patient Multiple Birth Indicator - No
Patient Birth Order - NA
Responsible Person Name: First - Manuel
Responsible Person Name: Middle - Marcel
Responsible Person Name: Last - Gonzales
Responsible Person Name: Relationship to Patient - Father
Mother's Name: First - Anita
Mother's Name: Middle - Francesca
Mother's Name: Last - Gonzales
Mother's Name: Maiden Last - Morales
Patient Address: Street - 4623 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Shoreline Hospital 325 Shorline Drive, Stamford Connecticut 06901
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1213
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Phone

Notes for Testers
No Note

3.1.2. Query Registry for vaccination history and forecast for Juan Marcel Gonzales

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre Condition
Juan Marcel Gonzales Initial Data Load is completed.

Post Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juan Marcel Gonzales.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juan	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20140304	Value-Test Case Fixed
QPD-7	Patient Sex	M	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4623 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551213	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N	Value-Test Case Fixed
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juan	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20140304	Value-Test Case Fixed
QPD-7	Patient Sex	M	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4623 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551213	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N	Value-Test Case Fixed
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juan Marcel Gonzales
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	03/04/2014
Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903
Patient Phone	(203)555-1213
Birth Indicator	No
Birth Order

Patient Information

Element	Data
Patient Name	Juan Marcel Gonzales
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	03/04/2014
Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903
Patient Phone	(203)555-1213
Birth Indicator	No
Birth Order

3.1.3. View and import response to request for vaccination history for Juan Marcel Gonzales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR

Test Story

Description

The physician accesses the record for Juan Marcel Gonzales and:

• Accepts the vaccines provided by the registry as this is a new patient and there are no prior vaccines recorded

• Views the registry history including the second dose of Hepatitis B vaccine given late (at 2 years of age) and no history of a third dose; influenza vaccine was also not given since 2013

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre Condition

A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juan Marcel Gonzales)

Test Objectives

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. The user imports returned vaccinations as follows:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/23/2011

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 12/23/2013
Verify that the EMR is alerted that this dose was given too late

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2012

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/22/2012

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/21/2012

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/20/2013

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2012

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/22/2012

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/21/2012

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/22/2012

poliovirus vaccine, inactivated (CVX 10) administered 1/22/2012

poliovirus vaccine, inactivated (CVX 10) administered 3/22/2012

poliovirus vaccine, inactivated (CVX 10) administered 5/21/2012

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2012

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/22/2012

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/21/2012

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 11/22/2012

rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2012

rotavirus, live, monovalent vaccine (CVX 119) administered 3/22/2012

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/22/2012

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/20/2012

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/30/2013

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/21/2013

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 12/1/2013

measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 11/22/2012

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juan
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	L
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201403041100
QPD-7	Patient Sex	M
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551213
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	94
OBX-5.2	Text	MMRV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	24
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	25
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	26
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	83
OBX-5.2	Text	HepA
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juan
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	L
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201403041100
QPD-7	Patient Sex	M
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551213
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	94
OBX-5.2	Text	MMRV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	24
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	25
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	26
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	83
OBX-5.2	Text	HepA
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juan Marcel Gonzales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juan Marcel Gonzales
Date of Birth	03/04/2014
Sex	Male
Address 1
Street	4623 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Anita Francesca Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Shoreline Hospital
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	03/03/2014
Date/Time Administration-End	03/03/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	325 Shorline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	04/15/2014
Date/Time Administration-End	04/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	05/15/2014
Date/Time Administration-End	05/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	07/13/2014
Date/Time Administration-End	07/13/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	09/16/2014
Date/Time Administration-End	09/16/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	09/20/2015
Date/Time Administration-End	09/20/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/14/2014
Date/Time Administration-End	05/14/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/04/2015
Date/Time Administration-End	05/04/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	05/14/2014
Date/Time Administration-End	05/14/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	10/15/2014
Date/Time Administration-End	10/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/18/2014
Date/Time Administration-End	05/18/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/04/2015
Date/Time Administration-End	05/04/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	05/18/2014
Date/Time Administration-End	05/18/2014
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Thigh Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	10/20/2015
Date/Time Administration-End	10/20/2015
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	Hepatitis A
Refusal Reason
Date/Time Administration-Start	05/15/2015
Date/Time Administration-End	05/15/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMRV
Vaccine Administered	MMR and Varicella
Refusal Reason
Date/Time Administration-Start	10/20/2015
Date/Time Administration-End	10/20/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	08/30/2014
Earliest Date to Give	08/30/2014
Latest Date to Give	08/30/2015
Date When Vaccine Overdue	08/31/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2016
Earliest Date to Give	08/30/2015
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	HepA
Vaccine Due Date	08/30/2015
Earliest Date to Give	08/30/2015
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason

3.1.4. View the vaccination forecast for Juan Marcel Gonzales returned by the Immunization Registry

Test Step Type: TA_RESPONDER
The EMR displays the current Immunization Forecast to the user for Juan Marcel Gonzales as returned by the Immunization Registry Z42 response.

Test Story

Description

The physician accesses the record for Juan Marcel Gonzales and:

• Views the vaccine forecast provided by the Immunization Registry

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing

Post Condition
The vaccine forecast from the Immunization Registry is available for viewing in the EMR.

Test Objectives
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast.

Evaluation Criteria
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juan
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	L
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201403041100
QPD-7	Patient Sex	M
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551213
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	94
OBX-5.2	Text	MMRV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	24
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	25
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	26
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	83
OBX-5.2	Text	HepA
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juan
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	L
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201403041100
QPD-7	Patient Sex	M
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551213
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	5
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	6
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	7
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	8
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	10
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	11
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	12
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	14
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	15
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	16
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	18
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	19
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	20
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	94
OBX-5.2	Text	MMRV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	24
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	25
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	26
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	83
OBX-5.2	Text	HepA
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150830
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200301
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200302
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	27
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juan Marcel Gonzales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juan Marcel Gonzales
Date of Birth	03/04/2014
Sex	Male
Address 1
Street	4623 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Anita Francesca Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Shoreline Hospital
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	03/03/2014
Date/Time Administration-End	03/03/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	325 Shorline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	04/15/2014
Date/Time Administration-End	04/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	05/15/2014
Date/Time Administration-End	05/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	07/13/2014
Date/Time Administration-End	07/13/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	09/16/2014
Date/Time Administration-End	09/16/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	09/20/2015
Date/Time Administration-End	09/20/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/14/2014
Date/Time Administration-End	05/14/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/04/2015
Date/Time Administration-End	05/04/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	05/14/2014
Date/Time Administration-End	05/14/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	10/15/2014
Date/Time Administration-End	10/15/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/18/2014
Date/Time Administration-End	05/18/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/04/2015
Date/Time Administration-End	05/04/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	05/18/2014
Date/Time Administration-End	05/18/2014
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	07/21/2014
Date/Time Administration-End	07/21/2014
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Thigh Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	09/27/2014
Date/Time Administration-End	09/27/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	10/20/2015
Date/Time Administration-End	10/20/2015
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	Hepatitis A
Refusal Reason
Date/Time Administration-Start	05/15/2015
Date/Time Administration-End	05/15/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMRV
Vaccine Administered	MMR and Varicella
Refusal Reason
Date/Time Administration-Start	10/20/2015
Date/Time Administration-End	10/20/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	SC
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	08/30/2014
Earliest Date to Give	08/30/2014
Latest Date to Give	08/30/2015
Date When Vaccine Overdue	08/31/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2016
Earliest Date to Give	08/30/2015
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	HepA
Vaccine Due Date	08/30/2015
Earliest Date to Give	08/30/2015
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	03/02/2018
Earliest Date to Give	03/02/2018
Latest Date to Give	03/01/2020
Date When Vaccine Overdue	03/02/2020
Status in Immunization Series
Forecast Reason

3.1.5. View the vaccination forecast for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juan Marcel Gonzales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juan Marcel Gonzales and, once the vaccine history is reconciled in the EMR, the vaccine forecast is updated :

• The provider views the updated vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
The vaccine forecast may be imported from the Immunization Registry Vaccination History and Forecast (Z42) response, or it may be generated by EMR defined means.

Pre Condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juan Marcel Gonzales)

Post Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: 2. Verify that the EMR includes in the vaccine forecast: Hep B Peds NOS due on 5/21/2012 DTaP due on 11/22/2015 IPV due on 11/22/2015 MMR due on 11/22/2015 Varicella due on 11/22/2015 influenza, unspecified formulation due on Oct 22, 2015 or later

Notes for Testers
No Note

3.2. Juan Marcel Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

3.2.1. Order intranasal, live virus influenza vaccine and view asthma contraindication

Test Step Type: SUT_MANUAL
Selects selects to order intranasal, live virus influenza vaccine and views information about patient asthma problem which is a contraindication to the intranasal vaccine.

Test Story

Description

The physician accesses the record for Juan Marcel Gonzales and:

• Orders administration of Influenza vaccine (intranasal, live virus vaccine)

• Receives notification the patient has asthma, a relative contraindication for intranasal influenza vaccine

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

Post Condition
User notified of history of contraindication tto nfluenza virus vaccine, live, attenuated, for intranasal use (CVX 111) of asthma on problem list. Order is changed to Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) .

Test Objectives

Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses.

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	influenza virus vaccine, live, attenuated, for intranasal use (CVX 111)
Date/Time Vaccine Refusal was recorded	Current Date
Alert	Notification the patient has asthma, a relative contraindication for intranasal influenza vaccine.

The Provider changes the order to:

Vaccine Type:

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

Notes for Testers
No Note

3.2.2. Orders administration of Hepatitis B vaccine

Test Step Type: SUT_MANUAL
The provider orders a Hepatitis B vaccine (dose 3).

Test Story

Description
As indicated by the vaccine forecast, the third Hepatitis B is overdue, and is ordered.

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast reviewed.

Post Condition
Hepatitis B vaccine is ordered for the patient.

Test Objectives
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Order Value/Text for Vaccine Type	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
Date/Time Vaccine was recorded	Current Date

Notes for Testers
No Note

3.2.3. Orders administration of DTaP vaccine and alerted that the dose is too early

Test Step Type: SUT_MANUAL
The provider orders a DTaP vaccine (dose 5). The EMR provides an alert that the vaccine dose is too early.

Test Story

Description
The fifth DTaP is ordered, and the provider is notified that the dose is too early.

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast is available in the EMR.

Post Condition
DTaP vaccine is ordered for the patient, and provider is notified that the dose is too early.

Test Objectives

Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
Date/Time Vaccine order was recorded	Current Date
Alert	Notification that the dose is too early

Notes for Testers
No Note

3.2.4. Records Hepatitis B Vaccine lot number with expired lot alert

Test Step Type: SUT_MANUAL
The provider records the vaccine administration lot number in the EMR and is alerted of the expired lot.

Test Story

Description
The nurse documents administration lot number for the Hepatitis B vaccine • Is prevented from ordering the Hepatitis B lot as it has expired • Documents administration from a different lot that is not expired

Comments

Pre Condition
Order is placed for Hepatitis B vaccine.

Post Condition
The provider has been notified of the expired Hepatitis B vaccination lot. Documentation of a lot to be administered that is not expired is recorded in the EMR.

Test Objectives
Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)
Lot Number (Expired)	6332FK18
Substance Expiration Date (Expired)	6/15/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)
Alert	Alerts user to expired lot

Notes for Testers
No Note

3.2.5. Record Hepatitis B Vaccine administration

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the the Hepatitis B vaccine
• Documents all required information for the vaccine

Comments
No Comments

Pre Condition
Order is placed for Hepatitis B vaccine.

Post Condition
The Hepatitis B vaccination is recorded in the EMR.

Test Objectives

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administration Notes
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	6332FK26
Substance Expiration Date	8/25/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)
Completion Status	CP
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)
Administration Site	Left Deltoid (HL70162 LD)
VFC Eligibility	No

Notes for Testers
No Note

3.2.6. Records Influenza Vaccine administration with VFC eligibility checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration from a VFC source and alerted that the patient is not VFC eligible.

Test Story

Description
The nurse documents administration for the inactivated influenza vaccine from a VFC source • Is alerted that the patient is not eligible for VFC • Orders a different non-VFC lot of inactivated influenza vaccine

Comments
This step covers data quality checking as an informative aspect of vaccine administration

Pre Condition
Order is placed for inactivated influenza vaccine.

Post Condition
The user is notified of vaccine dose ineligibility.

Test Objectives
Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected.

Evaluation Criteria

The provider documents a VFC lot to be administered in the EMR. Once notified that the patient is not eligible for the VFC, the a non-VFC lot is selected.

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Date/Time of Start of Administration	Current Date
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
VFC lot (not administered)	D8043IN8422
Substance Expiration Date	8/15/2015
Substance Manufacturer Name	Sanofi Pasteur (MVX PMC)
Alert	Patient is not VFC Eligible

The Provider selects a non-VFC Lot:

Vaccine Lot # (administered):	D8043IN8855
Vaccine Expiration Date:	8/25/2015

Notes for Testers
No Note

3.2.7. Record Influenza Vaccine administration for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the inactivated influenza vaccine
• Documents all required information for each vaccine

Comments
No Comments

Pre Condition
Order is placed for inactivated influenza vaccine.

Post Condition
The inactivated influenza vaccine administration is recorded in the EMR.

Test Objectives

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source (Administration Notes)	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Date/Time of Start of Administration	Current Date
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Administered Amount (of Vaccine)	0.25
Administered Units (of Measure)	mL
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	D8043IN8855
Substance Expiration Date	8/25/2015
Substance Manufacturer Name	Sanofi Pasteur (MVX PMC)
Completion Status	CP
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)
Administration Site	Left Thigh (HL7 LT)
VFC Eligibility	No

Notes for Testers
No Note

3.3. Juan Marcel Gonzales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juan Marcel Gonzales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

3.3.1. Transmit the Immunization Report for Juan Marcel Gonzales

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS.

Pre Condition
The vaccines for the visit have been administered.

Post Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551213
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20140304
PD1-18	Publicity Code Effective Date	20140304

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Manuel
NK1-2.3	Second and Further Given Names or Initials Thereof	Marcel
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	FTH
NK1-3.2	Text	Father
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4623 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06903
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551213

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK34
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK2
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151001
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK26
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2434
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4577
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5535
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151014
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2444
RXA-16	Substance Expiration Date
RXA-16.1	Time	2014100304
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8445
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2175
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58544
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150118
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV543
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141029
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV933
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8738
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8798
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8855
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT35
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT47
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7W27V7632
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20120202
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201403041100
PID-8	Administrative Sex	M
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551213
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20140304
PD1-18	Publicity Code Effective Date	20140304

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Manuel
NK1-2.3	Second and Further Given Names or Initials Thereof	Marcel
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	FTH
NK1-3.2	Text	Father
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4623 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06903
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551213

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J.
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140303
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK34
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6352FK2
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151001
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK26
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS2434
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150920
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M54K9255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M55K3343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M75K4577
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7M53K5535
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151014
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV2444
RXA-16	Substance Expiration Date
RXA-16.1	Time	2014100304
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P243V3321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P343V8445
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V2175
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	P853V58544
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150118
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV543
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141029
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140721
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RV933
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8738
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8798
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	D8043IN8855
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150515
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT35
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	Hepatitis A
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6359RT47
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161031
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151020
RXA-5	Administered Code
RXA-5.1	Identifier	94
RXA-5.2	Text	MMR and Varicella
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	7W27V7632
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	SC
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20120202
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS Presentation Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150715
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juan Marcel Gonzales
Mother's Maiden Name	Anita Morales
ID Number	123456 987633
Date/Time of Birth	03/04/2014 11:00
Administrative Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1213
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	03/04/2014
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	03/04/2014
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Manuel Marcel Gonzales
Relationship	Father
Address	4623 Standish Way Stamford CT 06903
Phone Number	(203)555-1213

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	03/03/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6332FK34
Substance Expiration Date	12/14/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	04/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6352FK2
Substance Expiration Date	10/01/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6332FK26
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	02/02/2012
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	05/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2342
Substance Expiration Date	11/30/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	07/13/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2434
Substance Expiration Date	09/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	09/16/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	09/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	03/01/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/14/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M54K9255
Substance Expiration Date	03/24/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M55K3343
Substance Expiration Date	10/30/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M75K4577
Substance Expiration Date	05/23/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/04/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M53K5535
Substance Expiration Date	10/14/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	05/14/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV2444
Substance Expiration Date	10/03/2014
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	03/23/2015
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	02/22/2015
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/18/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P243V3321
Substance Expiration Date	01/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P343V8445
Substance Expiration Date	03/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V2175
Substance Expiration Date	08/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/04/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V58544
Substance Expiration Date	01/18/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	05/18/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV543
Substance Expiration Date	10/29/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV933
Substance Expiration Date	05/10/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Thigh Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8738
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	10/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8798
Substance Expiration Date	05/22/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	10/31/2015
Administered Amount	0.25
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	D8043IN8855
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis A
Date/Time Start of Administration	05/15/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RT35
Substance Expiration Date	01/04/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis A
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6359RT47
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	MMR and Varicella
Date/Time Start of Administration	10/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7W27V7632
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Patient Information

Element	Data
Patient Name	Juan Marcel Gonzales
Mother's Maiden Name	Anita Morales
ID Number	123456 987633
Date/Time of Birth	03/04/2014 11:00
Administrative Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1213
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	03/04/2014
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	03/04/2014
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Manuel Marcel Gonzales
Relationship	Father
Address	4623 Standish Way Stamford CT 06903
Phone Number	(203)555-1213

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	03/03/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6332FK34
Substance Expiration Date	12/14/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	04/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6352FK2
Substance Expiration Date	10/01/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/31/2015
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6332FK26
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	02/02/2012
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	05/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2342
Substance Expiration Date	11/30/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	07/13/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2434
Substance Expiration Date	09/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	09/16/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	09/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	03/01/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/14/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M54K9255
Substance Expiration Date	03/24/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M55K3343
Substance Expiration Date	10/30/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M75K4577
Substance Expiration Date	05/23/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/04/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M53K5535
Substance Expiration Date	10/14/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	05/14/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV2444
Substance Expiration Date	10/03/2014
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	03/23/2015
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	10/15/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	02/22/2015
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/18/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P243V3321
Substance Expiration Date	01/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P343V8445
Substance Expiration Date	03/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V2175
Substance Expiration Date	08/30/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/04/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V58544
Substance Expiration Date	01/18/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	05/18/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV543
Substance Expiration Date	10/29/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	07/21/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV933
Substance Expiration Date	05/10/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Thigh Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	09/27/2014
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8738
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	10/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8798
Substance Expiration Date	05/22/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	10/31/2015
Administered Amount	0.25
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	D8043IN8855
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis A
Date/Time Start of Administration	05/15/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RT35
Substance Expiration Date	01/04/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis A
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6359RT47
Substance Expiration Date	10/31/2016
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	07/15/2015
vaccine fund pgm elig cat	Not VFC elig

Vaccine Administration Information

Element	Data
Administered Vaccine	MMR and Varicella
Date/Time Start of Administration	10/20/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7W27V7632
Substance Expiration Date	12/15/2016
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	SC
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

3.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre Condition
A VXU message is generated by the EHR.

Post Condition
The ACK Z23 is received by the EHR.

Test Objectives
No Test Objectives

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes for Testers
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

3.4. Juan Marcel Gonzales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

3.4.1. Produce an immunization report for Juan Marcel Gonzales including all history

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
*Produce Standard Patient Immunization History Report:* The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria

The following patient demographics are displayed:

Patient Identifier Number: Vendor Assigned

Patient Identifier Type Code: Vendor Assigned

Patient Name: Juan Marcel Gonzales

Date/Time of Birth: 3/4/2014 11:00am

Sex: Male

Patient Address: 4623 Standish Way, Stamford, CT 06903

Multiple Birth: N

Birth Order: NA

The following Vaccination History is displayed:

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 3/4/2014

Additional Observations:

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Jane Carter

Entered By: Lisa Sirtis

Entering Organization: Shoreline Hospital

Administered Amt: .05 mL

Administering Provider: Jane Carter

Administered at Location: 325 Shorline Drive,

Stamford Connecticut 06901

Lot#: 6332FK34

Exp Date: 12/14/2014

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 4/15/2014

Additional Observations:

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 6352FK2

Exp Date: 10/1/2015

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: Current Date

Additional Observations:

Dose #: 3

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Sandra Molina

Entered By: Frank Smith

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: 6332FK26

Exp Date: 10/31/2016

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL70162 LD)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 5/15/2014

Additional Observations:

Dose #: 1

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D409QS2342

Exp Date: 11/30/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 7/13/2014

Additional Observations:

Dose #: 2

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D409QS2434

Exp Date: 9/4/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 916/2014

Additional Observations:

Dose #: 3

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D409QS3256

Exp Date: 12/1/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 9/20/2015

Additional Observations:

Dose #: 3

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D409QS3256

Exp Date: 3/1/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 5/14/2014

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 7M54K9255

Exp Date: 3/24/2015

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 7/21/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 7M55K3343

Exp Date: 10/30/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 9/27/2014

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 7M75K4577

Exp Date: 5/23/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 5/4/2015

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 7M53K5535

Exp Date: 10/14/2015

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)"

Date Administered: 5/14/2014

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D333PV2444

Exp Date: 10/4/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)"

Date Administered: 7/21/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D333PV4343

Exp Date: 3/23/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 10/15/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D335PV9654

Exp Date: 2/22/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 5/18/2014

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: P243V3321

Exp Date: 1/30/2015

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 7/21/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: P343V8445

Exp Date: 3/30/2015

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 9/27/2014

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: P853V2175

Exp Date: 8/30/2015

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 5/4/2015

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: P853V58544

Exp Date: 10/18/2015

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 5/18/2014

Additional Observations:

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 6359RV533

Exp Date: 10/29/2014

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 7/21/2014

Additional Observations:

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 6359RV932

Exp Date: 5/10/2015

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 9/27/2014

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D8043IN8734

Exp Date: 3/12/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 10/20/2015

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D8043IN8798

Exp Date: 5/22/2016

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: Current Date

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Sandra Molina

Entered By: Frank Smith

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: D8043IN8855

Exp Date:10/31/2016

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: 5/15/2015

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 6359RT35

Exp Date: 1/4/2016

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Deltoid (HL7 RD)

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: Current Date

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 6359RT47

Exp Date: 10/31/2016

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: MMRV

Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)

ProQuad (NDC 00006-4999-00)"

Date Administered: 10/20/2015

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: 7W27V7632

Exp Date: 12/15/2016

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Thigh (HL7 LT)

The Following Vaccine Forecast is displayed:

Vaccine Group: HepB

Due Date: 11/22/2015

Earliest Date to Give: 08/30/2014

Latest Date to Give: 08/30/2015

Overdue Date: 08/31/2015

Immunization Schedule: ACIP

Vaccine Group: Dtap

Due Date: 3/3/2018

Earliest Date to Give: 3/3/2018

Latest Date to Give: 3/3/2020

Overdue Date: 3/4/2020

Immunization Schedule: ACIP

Vaccine Group: IPV

Due Date: 3/3/2018

Earliest Date to Give: 3/3/2018

Latest Date to Give: 3/3/2020

Overdue Date: 3/4/2020

Immunization Schedule: ACIP

Vaccine Group: Influenza

Due Date: 9/1/2016

Earliest Date to Give: 9/1/2016

Latest Date to Give: 1/31/2017

Overdue Date: 2/1/2017

Immunization Schedule: ACIP

Vaccine Group: HepA

Due Date: 11/22/2015

Earliest Date to Give: 8/30/2015

Immunization Schedule: ACIPVaccine Group: MMR

Due Date: 3/2/2018

Earliest Date to Give: 3/2/2018

Latest Date to Give: 3/1/2020

Overdue Date: 3/2/2020

Immunization Schedule: ACIP

Vaccine Group: Varicella

Due Date: 3/2/2018

Earliest Date to Give: 3/2/2018

Latest Date to Give: 3/1/2020

Overdue Date: 3/2/2020

Immunization Schedule: ACIP

Notes for Testers
No Note

4. Mariela Gonzales Morales Visit

No Description

4.1. Query the Registry for Mariela Gonzales Morales

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Mariela Gonzales Morales.

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Mariela Gonzales Morales. Querying the registry will consist of the vendor creating Z44 messages for Mariela Gonzales Morales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

4.1.1. Select Patient Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
Select patient Mariela Gonzales Morales, Infant Twin, distinguishing the patient from other patients with similar demographics (twins).

Test Story

Description
Mariela Gonzales Morales is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre Condition
Mariela Gonzales Morales Initial Data Load completed.

Post Condition
Mariela Gonzales Morales is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Mariela Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Mariela
Patient Name: Middle - Gonzales
Patient Name: Last - Morales
Patient Date of Birth - 10/01/2015
Birth Time - 11:00
Patient Gender (Administrative Sex) - F
Patient Multiple Birth Indicator - Yes
Patient Birth Order - 1
Responsible Person Name: First - Joanna
Responsible Person Name: Middle - Gonzales
Responsible Person Name: Last - Morales
Responsible Person Name: Relationship to Patient - Mother
Mother's Name: First - Joanna
Mother's Name: Middle - Gonzales
Mother's Name: Last - Morales
Mother's Name: Maiden Last - Gonzales
Patient Address: Street - 3321 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1214
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Phone

Notes for Testers
No Note

4.1.2. Query Registry for vaccination history and forecast for Mariela Gonzales Morales

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre Condition
Mariela Gonzales Morales Initial Data Load is completed.

Post Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Mariela Gonzales Morales.

Test Objectives

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales	Value-Test Case Fixed
QPD-4.2	Given Name	Mariela	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Gonzales	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20151001	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551214	Value-Test Case Fixed
QPD-10	Multiple birth indicator	1	Value-Test Case Fixed
QPD-11	Birth order	1	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales	Value-Test Case Fixed
QPD-4.2	Given Name	Mariela	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Gonzales	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20151001	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551214	Value-Test Case Fixed
QPD-10	Multiple birth indicator	1	Value-Test Case Fixed
QPD-11	Birth order	1	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Mariela Gonzales Morales
Mother's Maiden Name	Gonzales
ID Number	123456
Date/Time of Birth	10/01/2015
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	1

Patient Information

Element	Data
Patient Name	Mariela Gonzales Morales
Mother's Maiden Name	Gonzales
ID Number	123456
Date/Time of Birth	10/01/2015
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	1

4.1.3. View and import response to request for vaccination history for Mariela Gonzales Morales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR.

Test Story

Description

The physician accesses the record for Mariela Gonzales Morales and:

??? Accepts the single vaccine in the registry record into the EHR history

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre Condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Mariela Gonzales Morales)

Test Objectives

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. The user imports returned vaccinations as follows:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/30/2015

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Mariela
QPD-4.3	Second and Further Given Names or Initials Thereof	Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201503301100
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Mariela
QPD-4.3	Second and Further Given Names or Initials Thereof	Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201503301100
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Mariela Gonzales Morales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	BG2 Morales
Date of Birth	03/30/2015
Sex	Female
Address 1
Street	3321 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Joanna Gonzales Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Stamford Regional Hospital
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	10/01/2015
Date/Time Administration-End	10/01/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	Susan Pike
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	15 Atlantic Avenue
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	10/31/2015
Earliest Date to Give	10/31/2015
Latest Date to Give	11/30/2015
Date When Vaccine Overdue	12/01/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hib
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Pneumococcal Conjugate, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	rotavirus, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	08/31/2016
Earliest Date to Give	08/31/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, unspecified formulation
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason

4.1.4. View the vaccination forecast for Mariela Gonzales Morales returned by the Immunization Registry

Test Step Type: TA_RESPONDER
The EMR displays the current Immunization Forecast to the user for Mariela Gonzales Morales as returned by the Immunization Registry Z42 response.

Test Story

Description

The physician accesses the record for Mariela Gonzales Morales and:

??? Views the vaccine forecast provided by the Immunization Registry

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing

Post Condition
The vaccine forecast from the Immunization Registry is available for viewing in the EMR.

Test Objectives
*View Immunization Forecast:* The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast.

Evaluation Criteria
The EMR displays the information returned from the Immunization Registry according to the Juror Document.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201503301100
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Pike
ORC-10.3	Given Name	Susan
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Parker
ORC-12.3	Given Name	Justin
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201503301100
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551212
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Pike
ORC-10.3	Given Name	Susan
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Parker
ORC-12.3	Given Name	Justin
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Clerk
ORC-10.3	Given Name	Myron
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname
ORC-12.3	Given Name
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20151214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	BG2 Morales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	03/30/2015 11:00
Administrative Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2015
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Stamford Regional Hospital
Entered By	Susan Pike
Ordered By	Justin Parker

Element	Data
vaccine type	Hep B Peds NOS
dose number in series
number of doses in series

Immunization Schedule used	ACIP
Dose validity

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hep B, unspecified formulation
Earliest date to give	10/31/2015
Date vaccination due	10/31/2015
Latest date next dose may be given	11/30/2015
Date dose is overdue	12/01/2015

Immunization Schedule used	ACIP

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	DTaP, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hib
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	IPV
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Pneumococcal Conjugate, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	rotavirus, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	influenza, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	08/31/2016
Date vaccination due	08/31/2016

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hep A, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	09/30/2017
Date dose is overdue	10/01/2017

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	MMR

Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	12/29/2016
Date dose is overdue	12/30/2016

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Varicella
Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	12/29/2016
Date dose is overdue	12/30/2016

dose number in series

Patient Information

Element	Data
Patient Name	BG2 Morales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	03/30/2015 11:00
Administrative Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2015
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Stamford Regional Hospital
Entered By	Susan Pike
Ordered By	Justin Parker

Element	Data
vaccine type	Hep B Peds NOS
dose number in series
number of doses in series

Immunization Schedule used	ACIP
Dose validity

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hep B, unspecified formulation
Earliest date to give	10/31/2015
Date vaccination due	10/31/2015
Latest date next dose may be given	11/30/2015
Date dose is overdue	12/01/2015

Immunization Schedule used	ACIP

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	DTaP, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hib
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	IPV
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Pneumococcal Conjugate, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	rotavirus, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	11/30/2015
Date vaccination due	11/30/2015

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	influenza, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	08/31/2016
Date vaccination due	08/31/2016

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Hep A, unspecified formulation
Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	09/30/2017
Date dose is overdue	10/01/2017

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	MMR

Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	12/29/2016
Date dose is overdue	12/30/2016

dose number in series

Vaccine Administration Information

Element	Data
Administered Vaccine	no vaccine admin
Date/Time Start of Administration	06/01/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code
Route
Administration Site
Entering Organization	StateIIS
Entered By	Myron Clerk
Ordered By

Element	Data
vaccine type	Varicella
Immunization Schedule used	ACIP
Earliest date to give	09/30/2016
Date vaccination due	09/30/2016
Latest date next dose may be given	12/29/2016
Date dose is overdue	12/30/2016

dose number in series

4.1.5. View the vaccination forecast for Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Mariela Gonzales Morales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Mariela Gonzales Morales and:

• Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
No Comments

Pre Condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Mariela Gonzales Morales)

Post Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 6/29/2015
DTaP due on 7/29/2015
Hib due on 7/29/2015

IPV due on 7/29/2015

Pneumococcal conjugate due on 7/29/2015
Rotavirus due on 7/29/2015
HepA due on 5/29/2016
MMR due on 5/29/2016

Varicella due on 5/29/2016

influenza, unspecified formulation due on Nov 26, 2015 or later

Notes for Testers
No Note

4.2. Mariela Gonzales Morales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

4.2.1. Enter Initial Clinical Information for Mariela

Test Step Type: SUT_MANUAL
The EHR captures structured data indicating that Mariela has a fever in the current visit.

Test Story

Description
The triage nurse enters basic information on Mariela Gonzales Morales – she has a fever (Temperature of 100.8o F).

Comments
No Comments

Pre Condition
The EMR has recorded all of the pediatric demographic in the record created for Mariela Gonzales Morales.

Post Condition
The clinical record for Mariela Gonzales Morales indicates that she currently has a fever (temperature 100.8oF)..

Test Objectives
Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule): Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical data provided with all required attributes indicated by [Y]:

Vital Signs	Fever of 100.1 (@code LOINC 8310-5 @value 100.1)
Vital Signs Observation Date	Date of current visit
Problems (If vendor uses problems for alert computations, then this should be included.)	Problem list: ( Low grade pyrexia (finding) 304213008)
Problem Observation Date	Date of current visit

Notes for Testers
No Note

4.2.2. Enters a deferral for the vaccines due

Test Step Type: SUT_MANUAL
Enters a deferral for vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month.

Test Story

Description
The physician accesses the record for Mariela Gonzales Morales and: • Enters a deferral for the vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month

Comments
No Comment

Pre Condition
Prior Immunization History loaded and reconciled from the Immunization Registry. Vaccine forecast is available in the EMR indicating 5 vaccines are due: Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus

Post Condition
Vaccine deferral is recorded indicating the medical reason of low grade fever

Test Objectives
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) pneumococcal conjugate vaccine, 13 valent (CVX 133) rotavirus, live, monovalent vaccine (CVX 119)
Date/Time Vaccine not administered was recorded	Current Date
Alert	contraindication of fever
Substance/Treatment Deferral Start Date:Vaccination contraindication/precaution effective date (30946-8 LOINC)	Current Date
Substance/Treatment Deferral End Date/Vaccination temporary contraindication/precaution expiration date (30944-3 LOINC) :	Current Date +30 Days
Substance/Treatment Deferral Contraindication: Vaccination contraindication/precaution (30945-0 LOINC):	current fever with moderate-to-severe illness (PHVS_VaccinationContraindication_IIS - VXC23)
Completion Status:	NA
Date/Time Vaccine Deferral was recorded:	Current Date

Notes for Testers
No Note

4.3. Mariela Gonzales Morales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Mariela Gonzales Morales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

4.3.1. Transmit the Immunization Report for Mariela Gonzales Morales

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes the vaccine deferral and may include historical information updated in the EMR during the visit.

Test Story

Description
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS

Pre Condition
The vaccines for the visit have been administered.

Post Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	Mariela
PID-5.3	Second and Further Given Names or Initials Thereof	Gonzales
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Gonzales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	3321 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551214
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Morales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Gonzales
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	MTH
NK1-3.2	Text	Mother
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4623 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06903
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551213

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20101214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	DTaP, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	152
RXA-5.2	Text	Pneumococcal Conjugate, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	122
RXA-5.2	Text	rotavirus, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20120701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	Mariela
PID-5.3	Second and Further Given Names or Initials Thereof	Gonzales
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Gonzales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-10	Race
PID-10.1	Identifier	2106-3
PID-10.2	Text	White
PID-10.3	Name of Coding System	CDCREC
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	3321 Standish Way
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford
PID-11[1].4	State or Province	CT
PID-11[1].5	Zip or Postal Code	06903
PID-11[1].6	Country	USA
PID-11[1].7	Address Type	L
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN
PID-13.3	Telecommunication Equipment Type	PH
PID-13.4	Email Address
PID-13.6	Area/City Code	203
PID-13.7	Local Number	5551214
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2
PID-22.2	Text	Hispanic or Latino
PID-22.3	Name of Coding System	CDCREC
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data
PD1-11	Publicity Code
PD1-11.1	Identifier	02
PD1-11.2	Text	Reminder/Recall - any method
PD1-11.3	Name of Coding System	HL70215
PD1-12	Protection Indicator
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20120701
PD1-18	Publicity Code Effective Date	20120701

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Morales
NK1-2.2	Given Name	Joanna
NK1-2.3	Second and Further Given Names or Initials Thereof	Gonzales
NK1-2.7	Name Type Code	L
NK1-3	Relationship
NK1-3.1	Identifier	MTH
NK1-3.2	Text	Mother
NK1-3.3	Name of Coding System	HL70063
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4623 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford
NK1-4.4	State or Province	CT
NK1-4.5	Zip or Postal Code	06903
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN
NK1-5.3	Telecommunication Equipment Type	PH
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203
NK1-5.7	Local Number	5551213

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.9.1	Namespace ID
ORC-10.9.2	Universal ID
ORC-10.9.3	Universal ID Type
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.9.1	Namespace ID
ORC-12.9.2	Universal ID
ORC-12.9.3	Universal ID Type
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text	Historical information - from public agency
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Sirtis
RXA-10.3	Given Name	Lisa
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20101214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	DTaP, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	152
RXA-5.2	Text	Pneumococcal Conjugate, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151031
RXA-5	Administered Code
RXA-5.1	Identifier	122
RXA-5.2	Text	rotavirus, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0
OBX-3.2	Text	Vaccination contraindication
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23
OBX-5.2	Text	current fever with moderate-to-severe illness
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8
OBX-3.2	Text	Vaccination contraindication/precaution effective date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Mariela Gonzales Morales
Mother's Maiden Name	Joanna Gonzales
ID Number	123456 987633
Date/Time of Birth	10/01/2015 11:15
Administrative Sex	Female
Patient Address 1	3321 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1214
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Gonzales Morales
Relationship	Mother
Address	4623 Standish Way Stamford CT 06903
Phone Number	(203)555-1213

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	10/01/2015
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2010
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal Conjugate, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Patient Information

Element	Data
Patient Name	Mariela Gonzales Morales
Mother's Maiden Name	Joanna Gonzales
ID Number	123456 987633
Date/Time of Birth	10/01/2015 11:15
Administrative Sex	Female
Patient Address 1	3321 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1214
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2012
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2012
Protection Indicator
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Gonzales Morales
Relationship	Mother
Address	4623 Standish Way Stamford CT 06903
Phone Number	(203)555-1213

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	10/01/2015
Administered Amount	999
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Lisa Sirtis
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2010
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	IM
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal Conjugate, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, unspecified formulation
Date/Time Start of Administration	10/31/2015
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	07/15/2015
Vaccination temporary contraindication/precaution expiration date	12/01/2015

4.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre Condition
A VXU message is generated by the EHR.

Post Condition
The ACK Z23 is received by the EHR.

Test Objectives
No Test Objectives

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes for Testers
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20160224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

4.4. Mariana Gonzales Morales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

4.4.1. Produce an immunization report for Mariela Gonzales Morales including all history

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
*Produce Standard Patient Immunization History Report:* The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria

The following patient demographics are displayed:

Patient Identifier Number: Vendor Supplied

Patient Identifier Type Code: Vendor Supplied

Patient Name: Mariela Gonzales Morales

Date/Time of Birth: 03/30/2015 11:00am

Sex: Female

Patient Address: 3321 Standish Way, Stamford, CT 06903

Multiple Birth: Y

Birth Order: 1

The following Vaccination History is displayed:

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 11/23/2011

Additional Observations:

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Jane Carter

Entered By: Lisa Sirtis

Entering Organization: Shoreline Hospital

Administered Amt: .05 mL

Administering Provider: Jane Carter

Administered at Location: 325 Shorline Drive,

Stamford Connecticut 06901

Lot#: 6332FK34

Exp Date: 12/14/2011

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

The Following Vaccine Forecast is displayed:

Vaccine Group: Hep B Peds NOS

Due Date: 6/29/2015

Earliest Date to Give: 6/29/2015

Latest Date to Give: 7/29/2015

Overdue Date: 7/30/2015

Immunization Schedule: ACIP

Vaccine Group: Dtap

Due Date: 7/29/2015

Earliest Date to Give: 29-Jul-15

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: Hib

Due Date: 7/29/2015

Earliest Date to Give: 7/29/2015

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: IPV

Due Date: 7/29/2015

Earliest Date to Give: 7/29/2015

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: Pneumococcal conjugate

Due Date: 7/29/2015

Earliest Date to Give: 7/29/2015

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: Rotavirus

Due Date: 7/29/2015

Earliest Date to Give: 7/29/2015

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: Influenza

Due Date: Nov 26, 2015 or later

later

Earliest Date to Give: Nov 26, 2015

Latest Date to Give:

Overdue Date:

Immunization Schedule: ACIP

Vaccine Group: HepA

Due Date: 5/29/2016

Earliest Date to Give: 5/29/2016

Latest Date to Give: 5/29/2017

Overdue Date: 5/30/2017

Immunization Schedule: ACIP

Vaccine Group: MMR

Due Date: 5/29/2016

Earliest Date to Give: 5/29/2016

Latest Date to Give: 8/27/2016

Overdue Date: 8/28/2016

Immunization Schedule: ACIP

Vaccine Group: Varicella

Due Date: 5/29/2016

Earliest Date to Give: 5/29/2016

Latest Date to Give: 8/27/2016

Overdue Date: 8/28/2016

Immunization Schedule: ACIP

Notes for Testers
No Note

5. Juana Maria Gonzales Morales Visit

No Description

5.1. Query the Registry for Juana Maria Gonzales Morales.

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Maria Gonzales Morales

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Maria Gonzales Morales. Querying the registry will consist of the vendor creating Z44 messages for Juana Maria Gonzales Morales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre Condition
No PreCondition

Post Condition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes for Testers
No Note

5.1.1. Select Patient Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
Select patient Juana Maria Gonzales Morales, Infant Twin, distinguishing the patient from other patients with similar demographics (twins).

Test Story

Description
Juana Maria Gonzales Morales is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre Condition
Juana Maria Gonzales Morales Initial Data Load completed.

Post Condition
Juana Maria Gonzales Morales is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Juana Maria Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juana
Patient Name: Middle - Maria Gonzales
Patient Name: Last - Morales
Patient Date of Birth - 10/01/2015
Birth Time - 11:15
Patient Gender (Administrative Sex) - F
Patient Multiple Birth Indicator - Yes
Patient Birth Order - 2
Responsible Person Name: First - Joanna
Responsible Person Name: Middle - Gonzales
Responsible Person Name: Last - Morales
Responsible Person Name: Relationship to Patient - Mother
Mother's Name: First - Joanna
Mother's Name: Middle - Gonzales
Mother's Name: Last - Morales
Mother's Name: Maiden Last - Gonzales
Patient Address: Street - 3321 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1214
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Phone

Notes for Testers
No Note

5.1.2. Query Registry for vaccination history and forecast for Juana Maria Gonzales Morales

Test Step Type: SUT_INITIATOR
Vendor SHALL be able to Generate a Z44 Query correctly and without ommission according to supplied test data

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre Condition
Juana Maria Gonzales Morales Initial Data Load is completed.

Post Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales Morales.

Test Objectives

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20151001	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	1	Value-Test Case Fixed
QPD-11	Birth order	2	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20140515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID	MYEHR
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	20151001	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	1	Value-Test Case Fixed
QPD-11	Birth order	2	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales Morales
Mother's Maiden Name	Gonzales
ID Number	123456
Date/Time of Birth	10/01/2015
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	2

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales Morales
Mother's Maiden Name	Gonzales
ID Number	123456
Date/Time of Birth	10/01/2015
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	2

5.1.3. View and import response to request for vaccination history for Juana Maria Gonzales Morales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales Morales and:

• Accepts the single vaccine in the registry record into the EHR history

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre Condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Maria Gonzales Morales)

Test Objectives

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. The user imports returned vaccinations as follows:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/30/2015

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Maria Gonzales Morales.

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	BG2 Gonzales
Date of Birth	10/01/2015
Sex	Female
Address 1
Street	3321 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Joanna Gonzales Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Stamford Regional Hospital
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	10/01/2015
Date/Time Administration-End	10/01/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	Susan Pike
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	15 Atlantic Avenue
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	10/31/2015
Earliest Date to Give	10/31/2015
Latest Date to Give	11/30/2015
Date When Vaccine Overdue	12/01/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hib
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Pneumococcal Conjugate, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	rotavirus, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	08/31/2016
Earliest Date to Give	08/31/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, unspecified formulation
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason

5.1.4. View the vaccination forecast for Juana Maria Gonzales Morales returned by the Immunization Registry

Test Step Type: TA_RESPONDER
The EMR displays the current Immunization Forecast to the user for Juana Maria Gonzales Morales as returned by the Immunization Registry Z42 response.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales Morales and:

• Views the vaccine forecast provided by the Immunization Registry

Comments
No Comments

Pre Condition
A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing

Post Condition
The vaccine forecast from the Immunization Registry is available for viewing in the EMR.

Test Objectives
*View Immunization Forecast:* The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast.

Evaluation Criteria
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

Notes for Testers
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20091130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.6.1	Namespace ID	X68
MSH-22.6.2	Universal ID
MSH-22.6.3	Universal ID Type
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.6.1	Namespace ID
MSH-23.6.2	Universal ID
MSH-23.6.3	Universal ID Type
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.4.1	Namespace ID
QPD-3.4.2	Universal ID
QPD-3.4.3	Universal ID Type
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Morales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria Gonzales
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201510011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].4.1	Namespace ID	MYEHR
PID-3[1].4.2	Universal ID
PID-3[1].4.3	Universal ID Type
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].4.1	Namespace ID	MYIIS
PID-3[2].4.2	Universal ID
PID-3[2].4.3	Universal ID Type
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201510011115
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID	DCS_DC
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150601
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.9.1	Namespace ID
RXA-10.9.2	Universal ID
RXA-10.9.3	Universal ID Type
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-11.4.1	Namespace ID
RXA-11.4.2	Universal ID
RXA-11.4.3	Universal ID Type
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	31
OBX-5.2	Text	Hep B Peds NOS
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	3
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	4
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	9
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	13
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	17
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20151130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	21
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	23
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	28
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	30
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20160930
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59777-3
OBX-3.2	Text	Latest date next dose may be given
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161229
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20161230
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	31
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141216

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Maria Gonzales Morales.

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	BG2 Gonzales
Date of Birth	10/01/2015
Sex	Female
Address 1
Street	3321 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Joanna Gonzales Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Stamford Regional Hospital
Vaccine Group	Hep B Peds NOS
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	10/01/2015
Date/Time Administration-End	10/01/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	Susan Pike
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	15 Atlantic Avenue
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	10/31/2015
Earliest Date to Give	10/31/2015
Latest Date to Give	11/30/2015
Date When Vaccine Overdue	12/01/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hib
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Pneumococcal Conjugate, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	rotavirus, unspecified formulation
Vaccine Due Date	11/30/2015
Earliest Date to Give	11/30/2015
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	08/31/2016
Earliest Date to Give	08/31/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, unspecified formulation
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	09/30/2017
Date When Vaccine Overdue	10/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	09/30/2016
Earliest Date to Give	09/30/2016
Latest Date to Give	12/29/2016
Date When Vaccine Overdue	12/30/2016
Status in Immunization Series
Forecast Reason

5.1.5. View the vaccination forecast for Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juana Maria Gonzales Morales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales Morales and:

• Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
No Comments

Pre Condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Maria Gonzales Morales)

Post Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 6/29/2015
DTaP due on 7/29/2015
Hib due on 7/29/2015

IPV due on 7/29/2015

Pneumococcal conjugate due on 7/29/2015
Rotavirus due on 7/29/2015
HepA due on 5/29/2016
MMR due on 5/29/2016

Varicella due on 5/29/2016

influenza, unspecified formulation due on Nov 26, 2015 or later

Notes for Testers
No Note

6. Cohort Report

This test will consist of generating a cohort report to list all patients who are overdue for immunizations showing all overdue immunizations with the associated due/overdue dates.

6.1. Overdue Immunizations

List all patients who are overdue for immunizations showing all overdue immunizations.

Test Story

Description
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.

Post Condition
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR.

Test Objectives
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria

The following patient information is provided on the cohort report:

Patient Name	Mariela Gonzales Morales
Preferred Contact Method	Phone
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	5/30/2015 11am
Sex	Female
Vaccine Group	Hep B Peds NOS
Latest Date to Give	5/29/15
Overdue Date	5/29/15
Dose #	2
Dose in Series	3
Link to full record	Vendor Supplied

Patient Name	Juana Maria Gonzales Morales
Preferred Contact Method	Phone
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	5/30/2015 11:15am
Sex	Female
Vaccine Group	Hep B Peds NOS
Latest Date to Give	5/29/15
Overdue Date	5/29/15
Dose #	2
Dose in Series	3
Link to full record	Vendor Supplied

Notes for Testers
No Note

6.1.1. Produce Overdue Immunizations Cohort Report

Test Step Type: SUT_MANUAL
The provider uses the EMR to create a report for all patient vaccinations overdue with the contact information.

Test Story

Description
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.

Comments
No Comments

Pre Condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.

Post Condition
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR.

Test Objectives
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria

The following patient information is provided on the cohort report:

Patient Name	Mariela Gonzales Morales
Preferred Contact Method	Phone
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	10/01/2015 11am
Sex	Female
Vaccine Group	Hep B Peds NOS
Latest Date to Give	5/29/15
Overdue Date	5/29/15
Dose #	2
Dose in Series	3
Link to full record	Vendor Supplied

Patient Name	Juana Maria Gonzales Morales
Preferred Contact Method	Phone
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	10/01/2015 11:15am
Sex	Female
Vaccine Group	Hep B Peds NOS
Latest Date to Give	5/29/15
Overdue Date	5/29/15
Dose #	2
Dose in Series	3
Link to full record	Vendor Supplied

Notes for Testers
No Note